Patient/Relatives comment s Fantastic people, I knew what was happening to me and lots of attention (interview in A&E) 10 out of 10, first class service. Nothing to say other than positive things Real benefit that my father didn’t need to be admitted Nothing could be improved A&E was an experience – didn’t like how busy it was. (Interview in 72 hr bed) I didn’t want to come in but glad that it was just overnight More than I expected – gold star experience! (interview in CDU) Great that my husband could stay with me

ED Team comments It felt like we weren’t as busy but I wonder if it was actually that the flow through ED was simply better. Delighted with the outcomes – fabulous joint working and can see the process working This has been good but will seem worse next week when we go back to normal This could give us the better service that we want for patients This has to be better for patients, going home with the support that they need rather than being admitted Great feeling for the ED team to have help and support from others Really understand better what support is out there Relationships made now, will make it easier in the future

CASE STUDY 1 J.O. – 85 year old man Lives with wife and daughter – no external care No mobility aid but had fallen several times Stair lift in the house Presented via 999 call with severe abdominal pain – relieved with morphine and then a large bowel movement Recent constipation and history of prostatism with occasional urinary incontinence By time of arrival in the ED - painfree

CASE STUDY 1 Examination including of back passage revealed constipation and possible rectal polyp, low blood pressure and mild anaemia Mobile but unsteady and provided with a stick Discharged from the ED Dietician follow up, intermediate care team to do environmental check, provide ongoing physiotherapy and check adherence with laxatives Out patient colonoscopy arranged Nicorandil stopped in view of low blood pressure

CASE STUDY 2 M.N. 82 year old retired nurse Known to community mental health teams but no diagnosis reached – on most recent visit by consultant psychiatrist, large glass of mysterious brandy smelling liquid next to the bed – ‘that’s just water’…. Osteoarthritis GP referral with ‘acute confusional state’ Carers daily but sometimes unable to gain access No family or next of kin

CASE STUDY 2 Examination showed 4AT score of 6 – indicative of delirium Positive urinalysis with mild fever and frequency noted in the ED Mobile but unsteady and provided with stick Admitted to ‘72-hour bed’ Daily 4AT score showed improvements Urine infection confirmed and appropriate antibiotic prescribed. IV vitamins and alcohol withdrawal regime given. By day 2, mobile and more lucid Discharged day 3 with 4 visits/day (aiming to reduce), early mental health and alcohol liaison follow up in her own home

CASE STUDY 3 M.R. – 87 year old woman Nursing home resident for 6 years and completely dependent. Dementia. Bed bound. No advanced care plan BUT family and nursing home staff stated that they wanted her life to end in the home Admitted via 999 call with ‘pneumonia’ following GP visit

CASE STUDY 3 Phone call to nursing home and family from the ED quickly established wishes of usual carers Phone call to GP difficult…. ‘How are you planning to treat her pneumonia?’ Patient transported back to care home and died the following day Family attended the ED the following afternoon to personally thank the team

Staff comments at end of week Excited by the opportunities this presents. Not having to phone around and waste time getting services Better for patients! Someone having fallen could have been delayed for hours but this has meant a quicker turn around NH end of life care not needed active management Much more slick process Less moves must be of benefit to patients GP shadowing has been a good thing This has been good – how can it be mainstreamed to give a better service

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